10 Pearls from the Levitan Airway Course

Introduction

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Last week I attended Dr. Levitan's airway course in Baltimore.It was a teriffic course, which I would recommend to anyone looking to improve their airway management skills.For those of you unable to attend the course, here are some points which were particularly interesting to me.

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Pearl #10.Respect the vomit

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Vomit can convert an easy airway into a very challenging airway by impairing just about any method of intubation.Care should be taken to avoid this.If the patient is at high risk for emesis (i.e. GI bleed, intestinal obstruction, gastric ultrasound with full stomach, etc.), it may be wise to place a NG tube prior to intubation to suction the stomach. Intubating patients in reverse trendelenberg will make gravity work in your favor. Rapid-sequence intubation with careful attention to airway pharmacology also reduces the risk of vomiting…

Rocuronium was the favored paralytic agent in this course (this has been previously discussed in the epic video by Rubin Strayer below). Dr. Levitan suggests patiently waiting at least 60 seconds after rocuronium is injected before making any attempt to intubate. In the heat of the moment, there is a risk of initiating laryngoscopy before the patient is completely paralyzed, thus increasing the risk of vomiting. Using a high dose of rocuronium and waiting at least 60 seconds may add some safeguards against intubating before the patient is fully paralyzed. Please note that there is no guarantee that the patient will be paralyzed in 60 seconds, so the usual clinical tests of muscle tone should also be employed.0

Pearl #8.Don't over-utilize awake intubation

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There are certainly situations where awake intubation may improve safety (i.e., angioedema).However, this does have some important drawbacks.There is a greater risk of vomiting, and laryngeal exposure is more difficult.For most patients, an awake technique will not improve safety and may complicate matters.The likelihood of being unable to intubate (especially with videolaryngoscopy) and being unable to ventilate (either with an LMA or bag-valve mask) is generally extremely low. Although awake intubation certainly has its place, rapid-sequence intubation remains the workhorse of emergent airway management.

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Pearl #7.Consider a standard-geometry blade with video capability as your go-to blade for most challenging airways.

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When I trained, there were two options: traditional direct laryngoscopy or a Glidescope videolaryngoscope with a hyperangulated blade. Currently I have to a Storz CMAC videolaryngoscope with either standard-geometry Macintosh-style blades or a hyperangulated blade (the “difficult airway” blade, which is very similar to the hyperangulated Glidescope blade).When encountering a difficult airway, I still have a tendency to reach for the hyperangulated blade, based on my training.

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However, Levitan has persuaded me that the standard-geometry blade with video capability is the best way to go for most cases, since this combines the power of direct laryngoscopy with video laryngoscopy in a single tool.Issues such as endotracheal tube placement, suctioning the airway, and clearing foreign bodies are easier with a more direct approach.If the video camera is obscured by secretions, the operator can switch immediately to direct vision.The Glidescope has recently developed a standard geometry blade, and other products are on the horizon as well.Hyperangulated videolaryngoscopy remains useful for some patients with limited jaw or neck mobility.

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Pearl #6.Not all MAC-4 blades are created equal

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It's commonly taught that it's easier to err on the side of a longer blade (i.e., a MAC4), because you can always insert just a portion of the blade. However, I've had problems with the MAC4 blade impinging on the teeth, leading me to use a MAC3 on most of my intubations. Dr. Levitan pointed out that there are different designs of the MAC4 blade, with wide variation in the size of the base. American-style MAC4 blades have an enormous flange which limits maneuverability, whereas German blades have a smaller flange which is less likely to get caught on the teeth (see below). In retrospect, I've had bad experiences with the American MAC4.

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There is a great discussion about this on the Pharm blog by Mihn Le Cong.Bottom line?Know the exact specifications of every blade at your disposal (for example, the CMAC MAC4 and an American MAC4 are different).If possible, try acquiring blades with a lower profile.I agree with Drs. Le Cong and Levitan that a low-profile German MAC4 a good choice for the first pass.

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Pearl #5. Consider a stepwise midline approach if there is difficulty finding the epiglottis.

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The traditional approach to direct laryngoscopy with a Macintosh blade is to start on the right side of the mouth and sweep the tongue out of the way before proceeding to look for the epiglottis.If this is unsuccessful in revealing the epiglottis, an alternative approach is to advance the blade in a stepwise, gradual fashion directly down the tongue in the midline. When advancing the blade along the mideline, the epiglottis should lie right at the base of the tongue, directly within the course of the blade.

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Pearl #4.Have a strategy for improving a Grade IV View (epiglottis-only) with a Macintosh blade.

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Lets be honest.When a Grade IV view is encountered, the natural reaction is to panic.Thus, it's useful to have a pre-planned approach about how to optimize laryngeal exposure.There are four maneuvers which are very helpful here:

(a) Head elevation. This may be achieved by exerting force along the line of the laryngoscope handle, or by directly lifting the back of the head (often with the help of an assistant).

(c) Advance the blade further, right up to the base of the epiglottis. Inserting the blade too shallowly will expose the epiglottis, but will leave it hanging downward and obscuring the larynx. If the blade is inserted further into the base of the epiglottis, it will then cause the epiglottis to flip up, exposing the larynx.

(d) If the epiglottis is unusually long and/or floppy, it may hang down even with adequate placement of the blade. In this case, the blade may be advanced further to directly pick up the epiglottis (using the Macintosh blade like a Miller blade)(1).

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Pearl #3.Use straight-to-cuff stylet shaping.

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Straight-to-cuff stylet shaping prevents the tube from obscuring your view of the larynx while it is being inserted. This isn't particularly new, but I couldn't resist putting it in here because it is really pure gold. For more information see this video by Dr. Levitan:

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Pearl #2.What to do if the styletted endotracheal tube gets caught?

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What should you do if the endotracheal tube passes through the vocal cords but gets stuck in the trachea?Most of the time, this is due to the tube catching on the anterior tracheal rings.A 90-degree rotation should resolve this.

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Pearl #1.How can you do a cricothyrotomy on a patient without a palpable cricothyroid membrane?

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Paradoxically, many of the patients who need a cric will have poorly palpable neck anatomy.The key is finding midline and then making a large vertical incision.To find midline, gently palpating the lateral borders of the thyroid cartilage and rocking the thyroid cartilage back and forth may be helpful.Once the incision is made, stick your finger into it.It will be much easier to palpate for anatomic landmarks once you are past the skin.Thus, inability to palpate anatomic landmarks should not be interpreted as meaning that this procedure is impossible or contraindicated.00Need more Levitan? See this video on the EMCrit Blog.0

Notes

Thanks to Dr. Levitan for a great course and permission to write this blog. Appreciation also to the twenty people who volunteered to donate their body to medical science, allowing the cadaver lab component of this course to be possible.

(1) This list was not explicitly put forth by Dr. Levitan.It is a synthesis of material from the lectures as well as the practicum component of the course.

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Patrick

Levitan also promotes sitting up the obese patient, such that the ears and the anterior chest wall are on the same horizontal plane. I find this to be a useful manoeuvre, if you have the courage to really do it- the very heavy patient will be almost sitting upright!

Patrick

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3 years ago

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don

i think you mean using trendelenberg and not reverse trendellenberg to prevent aspiration

Both- T and Reverse T can 'theoretically' prevent aspiration. T- runs out of the mouth (ie if you breath in with gastric contents in the mouth–they will go into the airway thus only matters in paralyzed patients); Revere T- using gravity and regurgitation won't make it to the airway (ie less abd contents pushing on stomach, etc). Has anyone actually intubated a patient in a head down position- never have given that it would make intubating conditions worse in my opinion and seems as though the purpose of intubation is to intubate the patient while minimizing aspiration with RSI, which I think T would worsen my first chance success.